I have always found William Hogarth’s engravings fascinating – detailing both the trivia and the drama of ordinary lives in 18thCentury England. Many of them offer commentary on the problems of the day and perhaps also our own times?

In 1735 Hogarth completed a popular series of engravings entitled the “Rakes Progress”. These depicted a young mans debauched journey from a privileged start in life to his death in the infamous London Asylum called Bedlam. This name of this institution has passed into our speech as a term for a fearful and chaotic place.

Hogarth: The Rake in Bedlam

In the foreground of this picture we see the attendants removing the Rake’s chains (although I have read some saying that the chains are just being put on?). In death he is mourned only by the sweetheart he abandoned to pursue a life of drinking, gambling and womanising. As is typical of Hogarth’s work the rest of the picture is full of incident.

The cell on the left shows a “religious maniac”. His face contorts as he sees the shafts of sunlight coming through the bars which he sees as a spiritual visitation. In another cell a man who believes himself to be a king adopts a regal pose – harder to see is the pot he is pissing into. If you remember Dava Sobells book Longitude you will know about the struggle to figure out how to navigate around the world, the man with the telescope has lost his mind in the attempt. Other figures depict depression, a man who thinks he is the Pope and a mad tailor, a reminder of the tailor who measures him for a suit at the start of his progress. Two fashionably dressed women stand out from amongst the inmates.

These ladies have paid to tour Bedlam, this was a popular diversion of the day and a practice that was allowed until 1770 ( See thiswebsite for more details) . One of them is holding a fan to her face and is thought to be either trying to waft the stench from her face or possibly trying to hide the fact that she is laughing at the inmates. It is thought likely that Hogarth himself had toured this institution as it is said that architectural details (such as the bars which divide the “curables” from the “incurables”) are correct. Hogarth was closely involved in the foundation a few years later of the Foundling hospital – which cared for abandoned children. It seems reasonable to me to assume that he would have had a good reason to visit other institutions and didn’t go to Bedlam just to laugh? Whatever his reason to visit though we can be grateful that ideas have changed since Hogarth’s day – or have they?

Everyone is familiar with the experience of meeting a stranger at a party and going through the “what do you for a living” routine. Nowadays I say that I am a University Lecturer, but previously the revelation that I was a mental health nurse would often prompt a response such as “gosh you must be brave” or a request to talk about the sights I must have seen. If you are a mental health nurse – reflect on this yourself, do people have much idea of what mental health care is like or would their ideas more accurately fit Hogarths image?

Partly this may be due to media portrayals – try entering “schizophrenia” and “murder” into Google or recall the treatment Frank Bruno got from the Sun newspaper in the now infamous “Bonkers Bruno” headline. It is easy to question the press over some of this coverage, especially when the truth is that people with mental health problems are much more likely to be the victims than the perpetrators of violent crime (See MIND information for more details). It would be too easy (if not a little lazy?) to simply blame the press. Perhaps we all enjoy laughing at people who are perceived as different?

For example, I have laughed at some of the X factor auditions – there is an element of slapstick humour when things go horribly wrong but at the same time, being asked to join the laughter at films like this makes me uncomfortable. I have also come across this a few times as well – (whether this film is a fake or not) it is interesting to read the comments underneath.

What do you think? – I think we need to ask ourselves some questions:

What do we communicate to people about our work?

What responsibility do we have in promoting understanding about mental health issues?

Reflection – “a beautiful notion” may not be how you would describe this term!

Reflect, reflect, reflect, was all I heard from my tutors during the first three years of my nursing degree. I remember telling my friend ‘if they ask me to reflect one more time I think I am going to scream’. I could not get my head around what I was being asked to do. Why was it so important that every essay I wrote had to be reflective? As a consequence of my ignorance you can perhaps realise that most of my assignments barely scraped a pass and I was perceived as not the brightest of nursing students.

Then I met my last and final clinical assessor as a pre-reg nursing student, who opened my eyes to the wonderful world of reflection. I was fortunate enough to spend my 4th year in the company of a nurse who could see beyond my inability to pass assignments well and saw a student nurse with a brain who really wanted to learn (honestly!).

Every day after placement we would spend an hour going through the service users we had seen that day. I was asked questions about how I felt in different situations that had presented themselves to me. Not just what was good or bad, but if I was anxious we looked at why I was anxious and where had that anxiety stemmed from. If I felt confident about something we followed the same process. I was asked about why I had chosen a particular course of action, why was I concerned, where was my evidence for that intervention for that particular patient? What could I take away from today that would help me in the future, but importantly what had I learned about myself? During the course of my last year I grew in confidence as a practitioner and as a person. My assignments went from low level passes to A grades.

The difference between my attempts at reflecting on my own for assignments and my reflections with my clinical assessor was remarkable. I now realise that what my assessor was helping me to do was reflect ‘on action’, a retrospective contemplation of practice undertaken in order to uncover the knowledge used in a particular situation, by analysing and interpreting the information recalled, Schon (1983). But not only that my assessor was offering me ‘guided’ reflection. Johns, (2000), acknowledges that there are limits to reflecting alone and that guided reflection with a second person can allow the reflective process to become more meaningful. Students and practitioners often bring situations of emotional disturbance, grounded in such feelings as guilt, anger, anxiety, distress, conflict and inadequacy to guided reflection. The guide is there to help the student/practitioner to find meaning to the event, in order to understand and learn through and from it. As a consequence I matured and developed as a human being. I got to know myself better and became a healthier and more productive practitioner.

Burns and Bulman, (2000) suggest self-awareness is the foundation skill upon which reflective practice is built. I am not suggesting that final year taught me everything I needed to know about myself to be the perfect practitioner or human being, but what it did do was open my eyes to the wonderful world of reflection and raise my self awareness to a point that I no longer stumbled through life hitting the same road blocks over and over again. I still run into things every now again but never the same thing twice!

I am not sure that self awareness is something that we can teach our students but I do feel that our job as tutors and as clinical assessors is to offer the students the time and process that I was offered to help the student get to know themselves better and develop into good/healthy nurses.

I urge students to not shy away from reflection and to demand more from your personal tutors and clinical assessors.

Mental health nurses have been involved in the administration of depot neuroleptics ever since the first depots were designed in the 1960s. They are given by a deep intramuscular injection into the gluteal muscle every fortnight or so and are particularly useful for people with schizophrenia who we believe are not to be trusted with remembering to take their medication by themselves.

There appears to be a shift at the moment in the UK in the way depots are administered, away from an injection in the gluteus maximus (the dorsogluteal method, using the upper outer quadrant method to correctly site the injection), to the injection being given in the gluteus medius (the ventrogluteal or hip site, midway between the top of the hip bone and the crest of the pelvis). The old method is relatively more dangerous (the sciatic nerve is nearby, there is a large blood supply to this muscle), and we now also know that the chances of actually injecting the muscle using this method are quite poor, because there is a large amount of subcutaneous tissue around this muscle. One study has shown that as many as 19 out of 20 people might be being injected into fat rather than muscle. On the other hand, the ventrogluteal method is safer because there are no major nerves are arteries nearby, and we can inject into the muscle with greater confidence as there is less subcutaneous tissue around the gluteus medius. In short, we’ve not actually being treating people with the correct dose of neuroleptic for years, but now we can because we’re going to use a site that is more effective.

So this change in technique might lend weight, one way or another to the debate about whether neuroleptics actually work. The commonly held belief about neuroleptics is that they help regulate dopamine and other neurotransmitters in the brain, an overexcitation of dopamine being responsible for the so called positive symptoms of schizophrenia, such as the hearing of voices or having unusual thoughts. Some people take the view though that there is poor evidence to support this theory. A purely biological explanation for schizophrenia is unsatisfactory. Schizophrenia is a complex ‘illness’ which can be explained just as well in psychological or sociological terms than by the medical model. In fact, some say, there is no such thing as schizophrenia, and it’s not very helpful to be labelled so. Some service users will say that neuroleptics have never helped their voices go away, and some do not actually want this to happen anyway!

If you believe that neuroleptics help reduce the symptoms of schizophrenia, but now know that people on depots have not been receiving anywhere near the correct dose, what has been keeping people well for so long? Have people been well? Have we been actually defining wellness based on how willing the recipients of depots have been to drop their trousers every fortnight?

If you don’t believe that neuroleptics work, knowing that they’ve not been given correctly anyway adds a little bit of weight to your argument. But now that people are going to receive the correctly prescribed dose, we should be able to tell once and for all whether they work.

Although this is clearly an oversimplified way of looking at just one element of a well documented debate, think about this – how would you feel if you found out that the injection you were receiving (often unwillingly) for many years, wasn’t actually being given properly?

I have just been reading some work written by people looking at issues of stigma and discrimination in mental health, some of the material made me think quite a lot about this subject. Not only did the work state the obvious – things we already know such as people with a mental health issue treated differently to others, but it also examined the role of mental health nurses and I couldn’t help but recognise some of these statements were actually true.

Much is written about stigma and discrimination in mental health, particularly regarding service users, patients clients etc. Erving Goffman, in his book Stigma: Notes on the Management of Spoiled Identity (1963), describes stigma as ‘ a special kind of relationship between attribute and stereotype. An attribute that is deeply discrediting, that reduces the bearer from a whole and usual person to a tainted, discounted one. We believe that a person with stigma is not quite human. We tend to impute a wide range of imperfections on the basis of the original one. We may perceive his defensive response to his situation as a direct expression of his defect’. Goffman goes on to point out that stigma is generated in a social situation. It is a reaction by society that spoils a person’s identity by a set of imposed norms that are brought to bear on an encounter.

There are ‘them and us’ distinctions that underpin prejudice and discrimination and pervade mental heath services. People with mental health problems are devalued and, therefore those who work with them are also devalued by association: this is termed ‘courtesy stigma’ (Goffman 1963) or ‘stigma by association’ ( Neuberg et al 1994) The image of the psychiatric nurse compared to that of busy A&E ‘angel’ or life-giving midwife is seen very differently. Psychiatric nurses receive least recognition, affirmation, acknowledgement and validation from their family and friends (Cronin-Stubbs & Brophy 1985) and the psychiatric system as a whole is downgraded to a ‘Cinderella service’.

In an attempt to preserve our status, it might be tempting for mental health nurses to dissociate themselves from the devalued patients, to amplify differences in order to reduce the perceived threat from ‘out-group’ members (Heatherton et al 2003). When out with clients/patients/service users, it is often clearly demonstrated that you have not chosen to be with this person, that you are not a friend, neighbour, relative, but are with a patient AND are just doing your job!

Just a quick post to remind everyone to have a look at ‘Fundamentals of Mental Health Nursing’ which was published this month.

Fundamentals of Mental Health Nursing

The book is intended to cover the pre registration mental health nursing course and was written by a team of Mental Health Nurses – many (but not all) from Birmingham City University or the local trust. The book also benefits greatly from contributions by service users and student nurses.

The book is a little different in that it is partly an on-line resource, if you go to the publishers website you can access a lot of the supporting material from the book such as videos, quizzes and additional chapter material.

The book is intended as an intoduction for people who have had no previous experience of mental health nursing. We have also tried to write it in plain English – I believe that Mental Health Nursing isn’t rocket science! (although perhaps we sometimes make out that it is?) Anyway – for obvious reasons we are a bit biased about this so, take a look and see what you think about it , all comments welcome!

I’m getting a bit tired of the emphasis on just promoting physical health – what about mental health? Of course, five portions of fruit and vegetables are important, so is not smoking etc – of course mental health nurses have a role in this, but…

When I became a mental health nurse, it was because I believed that I could help people in distress. I found that I could easily talk to people and communicate on a variety of levels. I developed the ability to enter into someone’s ‘world’ to see it as they did. Indeed, as time passed I found that I had a particular skill in talking to those who were becoming physically aggressive to de-escalate the situation. I can spot side effects and help people who are experiencing these distressing consequences of the medication that we give. I can help a depressed person out of their hole and assist families to understand.

I have got some idea about physical needs, despite a relative lack of training in this area. I am not suggesting that I couldn’t spot the overweight person who smokes 40 a day and drinks alcohol like it is going out of fashion. Rather, what I am saying is my area is essentially concerned with facilitating people to enjoy their life. To give an example – I do not smoke, yet I will defend the rights of smokers to do so provided that they understand the potential consequences and do not force me to inhale their smoke. We are adults capable of making a decision. Surely my job is to facilitate the making of an informed decision? The Code of Conduct clearly states that we should respect the right of a patient to decline care yet too frequently if a patient declines then ‘no insight’ is recorded in their notes. I firmly believe that the majority of nurses break the Code on this point.

What about Mental Health promotion? WHO have identified that depression will be the number 1 illness in Europe by 2020 but rarely do I see any health promotion on this issue. The ubiquitous health promotion posters tell me to lose weight, stop drinking, stop smoking, lower my cholesterol, go jogging etc etc but I have never seen a poster saying

‘Hey! Go and chill out!’

And I probably never will. Yes I am well aware that many physical promotion has a knock on effect on mental health but surely we should be promoting factors that are primarily aimed at mental health promotion?

The candle that burns twice as brightly lasts half as long. Personally, I want to enjoy my life rather than extend a miserable one.

In common with most higher education institutions Birmingham City University courses use elements of e-learning to support the face to face taught sessions. We use a system called Moodle, which is considered to be the most popular learning management system in the world being used in 199 countries by 25,477 people (As at 17.12.2008 see link for latest figures) . Students studying Mental Health Nursing at the Faculty of Health are no exception.

BCU Mental Health Nursing Students

Individual course modules each have their own Moodle site, these are also grouped together into a single site called ‘The Mental Health Learning Community’. We have really tried to develop a good range of resources to support student learning such as filmed scenarios, quizzes and interactive resources. The intention was to try and make the online component of the course as accessible and interesting as possible. As part of this project an informal evaluation was carried out.

Over 200 students completed an evaluation survey which asked about their experience of using the online resources. The first sample of 142 students was taken between February and September 2007 and this was repeated with 60 students between October and November 2008. The survey suggests an interesting shift in the way students are using these resources.

Amongst the 2007 group, 12% stated that they rarely or never used the Moodle resources provided. There is quite a significant change over the course of a year as 100% of students surveyed accessed Moodle to some extent.

There are still some problems regarding ease of access. In response to the question ‘How easy did you find it to access the resources at University’ 30% found it ‘very easy’ in 2007 as compared with 32% a year later. Although no-one said they did not access it now (5% last year) there clearly remain some difficulties to look at.

Generally we were delighted with evidence suggesting that a large majority of students (98%) agreed that Moodle resources enhanced learning on the course to a ‘large extent’ or ‘some extent’. Again, this represents a positive shift towards acceptance of this resource.

These are just a few examples of the informal evaluation undertaken. This process is being used as part of a pilot study to be developed into a wider and more detailed research study to be completed over the course of 2009. Hopefully it should be possible to give information about this at a later date.

Blogroll

Carers Experts by experience
Support and Information Site For Families Friends or Relatives who provide help and support to a family member or friend with a mental health need living in the community. Carers outside of Plymouth are also welcome to contact me. I would also welcome any

Critical Psychiatry (UK)
On the site you will find papers and documents written by CPN in response to consultation documents from the National Institute for Health and Clinical Excellence in England (NICE).

Mental Health Foundation
Founded in 1949, the Mental Health Foundation is a leading UK charity that provides information, carries out research, campaigns and works to improve services for anyone affected by mental health problems, whatever their age and wherever they live.

Mental Health Update
Easy to understand summaries of research articles, all the latest information from the Department of Health and news stories from specialist journals.

Suman Fernando – personal website
This site provides information on issues around ‘race’ and ‘culture’ in relation to mental health in western multi-ethnic societies, social and mental health care in low and middle income (‘third world’) countries, racism in psychiatry.